B. INTRODUCTION

Typically, the person receives a title II Notice of Award that tells him/her that
he/she will receive an ongoing title II benefit, but we are withholding the retroactive
benefits so we can determine the reduction that is required by windfall offset. Subsequently,
we send the person a notice that states the windfall offset reduction. It is in the
windfall offset reduction notice that the person is told about the cross-program recovery.
The overpayment recovery is applied against the retroactive title II that remains
after the windfall offset reduction.

C. EXHIBIT: THE PARAGRAPH

When ___(1)___ received Supplemental Security Income (SSI) payments in the past, ___(2)___ received more than ___(3)___ should have. Our records show that you still owe us $___(4)___. Congress passed a law that permits us to collect SSI overpayments by withholding
from ___(5)___ Social Security benefits. We have withheld $___(6)___ from the Social Security benefits you were underpaid to collect the $___(7)___ that you owe.

FILL-INS

(1) you/he/she

(2) you/he/she

(3) you/he/she

(4) dollar amount of SSI overpayment

(5) your/his/her

(6) withholding amount

(7) dollar amount of SSI overpayment

D. Exhibit: A Sample Manual (MADCAP) Notice

Social Security Administration

Retirement, Survivors, and Disability Insurance

Important Information

Office Name

Street Address

City, State Zip

Date:
Month date, year

Claim
Number:

Claimant Name

Street address

City, State Zip

We are writing to give you new information about the disability benefits which you
receive on this Social Security record.

What We Will Pay

You will soon receive a check for $XXXXX.xx because we had withheld money from your benefits.

Reduction Due to Receipt of SSI

In an earlier letter, we told you we were withholding your Social Security benefits
for month year through month year. We did this because we thought we might have to reduce your Social Security benefits
if you also received Supplemental Security Income (SSI) money for this period.

Now we are writing to let you know that we cannot pay you of the Social Security benefits we withheld. This is because you received SSI money
for month year throughmonth year. When you receive SSI money for a month, and later you receive Social Security benefits,
we sometimes have to reduce your Social Security benefits. We do this to make sure
that your total SSI and Social Security monthly payment is not more than it would
have been if the Social Security benefits had been paid on time.

Allowing for your Social Security benefits, we should have paid you $XXXX.xx less
in SSI money. Because of this, we are reducing your Social Security benefits by $XXXX.xx.

Reduction to Collect Your SSI Overpayment

When you/he/she received Supplemental Security Income (SSI) payments in the past,
you/he/she received more than you/he/she should have. Our records show that you still
owe us $XXXX.xx. Congress passed a law that permits us to collect SSI overpayments by withholding
from your/his/her Social Security benefits. We have withheld $XXXX.xx from the Social Security benefits you were underpaid to collect the $XXXX.xx that you owe.

Do You Think That You Do Not Owe This Money?

You may ask us to review our finding that you still owe the money. You may have evidence
to show that you already paid some or all of the money or that we previously waived
collection of it. If so, give us this evidence when you ask for review. We will review
the evidence you give us and the information we have. We will send you a letter with
our decision. If we find that you do not owe us this amount, then we will correct
our records.

For more information on requesting review, see “Do You Think We Are Wrong?” below.

If You Think You Should Not Have to Pay Us Back

You may not have to pay us back. Sometimes we can waive the collection of an overpayment,
which means you won’t have to pay us back. For us to waive the collection of the overpayment,
two things have to be true.

•

It wasn’t your fault that you got too much SSI money.

AND

•

Paying us back would mean you can’t pay your bills for food, clothing, housing, medical
care or other necessary expenses, or it would be unfair for some other eason.

If you think these are true about you, contact any Social Security office. You can
ask for waiver at any time by completing the waiver form and returning it to us. The
form is called Request for Waiver of Recovery or Change in Repayment Rate, Form SSA-632.
We will be happy to help you fill out the form. If you ask for waiver, we will stop
collecting the overpayment while we decide if we can waive collection.

Do You Think We Are Wrong?

If you disagree with this decision, you have the right to appeal. We will review your
case and consider any new facts you have. A person who did not make the first decision
will decide your case. We will correct any mistakes. We will review those parts of
the decision which you believe are wrong and will look at any new facts you have.
We may also review those parts which you believe are correct and may make them unfavorable
or less favorable to you.

You have 60 days to ask for an appeal. The 60 days start the day after you get this
letter. We assume you got this letter 5 days after the date on it unless you show
us that you did not get it within the 5-day period. You must have a good reason for
waiting more than 60 days to ask for an appeal.

You have to ask for an appeal in writing. We will ask you to sign a form SSA-561-U2,
called "Request for Reconsideration". Contact one of our offices if you want help.

If You Want Help With Your Appeal

You can have a friend, lawyer or someone else help you. There are groups that can
help you find a lawyer or give you free legal services if you qualify. There are also
lawyers who do not charge unless you win your appeal. Your local Social Security office
has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must
approve the fee before he or she can collect it. And if you hire a lawyer, we will
withhold up to 25 percent of any past due benefits to pay toward the fee.

If You Have Any Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find
general information about Social Security. If you have any specific questions, you
may call us toll free at 1-800-772-1213, or call your local Social Security office
at [TRIDE/DOORS fill-in]. We can answer most questions over the phone. If you are deaf or hard of hearing,
you may call our TTY number, 1-800-325-0778. You can also write or visit any Social
Security office. The office that serves your area is located at:

District Office Name

Street

City/State Zip (Fill-in
from TRIDE/DOORS]

If you do call or visit an office, please have this letter with you. It will help
us answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment. This will help us serve you more quickly when you arrive at
the office.

E. Exhibit: A Sample Automated (AJS-3) Notice

Social Security Administration

Retirement, Survivors and Disability Insurance

Notice of Change in Benefits

Mid-America Program Service Center

601 East Twelfth Street

Kansas City, Missouri 64106-285

Date:

Claim Number: XXX-XX-XXXXA

XXXXXXXXXXXXXX

XXXXXXXXXXXXXXX

XXXXXXXXXXXX XX

In an earlier letter, we told you that you were entitled to Social Security but that
we were holding back benefits for July 2003 through October 2004. We withheld $XX,XXX.xx
in Social Security benefits.

We did this because our records showed you could have been getting Supplemental Security
Income (SSI) when we started paying you Social Security benefits. And Social Security
benefits can lower the amount of SSI payments you can receive.

What We Will Pay And When

You will receive $XX,XXX.xx around December 13, 2004.

This is the additional money you are due for July 2003 through October 2004.

After that, you will receive $XXX.xx on or about the third of each month.

What We Found

When we considered your Social Security and refigured your SSI, we found we should
have paid you $X,XXX.xx less in SSI money. We will take this from the Social Security
benefits we held.

Social Security Benefits Can Affect SSI Payments

The Social Security benefits you receive count as income and resources and can lower
the amount of SSI payments you can receive. When a person receives SSI money for a
month and later becomes entitled to Social Security for the same month, we have to
refigure the SSI payment. We hold back some of the Social Security benefits while
we do this, so the person doesn't owe if we've paid too much SSI.

Reduction to Collect Your SSI Overpayment

When you/he/she received Supplemental Security Income (SSI) payments in the past,
you/he/she received more than you/he/she should have. Our records show that you still
owe us $XXXX.xx. Congress passed a law that permits us to collect SSI overpayments by withholding
from your/his/her Social Security benefits. We have withheld $XXXX.xx from the Social Security benefits you were underpaid to collect the $XXXX.xx that you owe.

Do You Think That You Do Not Owe This Money?

You may ask us to review our finding that you still owe the money. You may have evidence
to show that you already paid some or all of the money or that we previously waived
collection of it. If so, give us this evidence when you ask for review. We will review
the evidence you give us and the information we have. We will send you a letter with
our decision. If we find that you do not owe us this amount, then we will correct
our records.

For more information on requesting review, see “If You Disagree With The Decision”
below.

If You Think You Should Not Have to Pay Us Back

You may not have to pay us back. Sometimes we can waive the collection of an overpayment,
which means you won’t have to pay us back. For us to waive the collection of the overpayment,
two things have to be true.

•

It wasn’t your fault that you got too much SSI money.

AND

•

Paying us back would mean you can’t pay your bills for food, clothing, housing, medical
care or other necessary expenses, or it would be unfair for some other reason.

If you think these are true about you, contact any Social Security office. You can
ask for waiver at any time by completing the waiver form and returning it to us. The
form is called Request for Waiver of Recovery or Change in Repayment Rate, Form SSA-632.
We will be happy to help you fill out the form. If you ask for waiver, we will stop
collecting the overpayment while we decide if we can waive collection.

If You Disagree With The Decision

If you disagree with our decision, you have the right to appeal. We will

review your case and consider any new facts you have. A person who did not

make the first decision will decide your case.

•

You have 60 days to ask for an appeal.

•

The 60 days start the day after you get this letter. We assume you got this letter
5 days after the date on it unless you show us that you did not get it within the
5-day period.

•

You must have a good reason for waiting more than 60 days to ask an appeal.

•

You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2,
called "Request for Reconsideration". Contact one of our offices to get the form or
if you need help to fill it out.

If You Want Help With Your Appeal

You can have a friend, lawyer or someone else help you. There are groups that can
help you find a lawyer or give you free legal services if you qualify. There are also
lawyers who do not charge unless you win your appeal. Your local Social Security office
has a list of groups that can help you with your appeal.

If you get someone to help you, you should let us know. If you hire someone, we must
approve the fee before he or she can collect it. And if you hire a lawyer, we will
withhold up to 25 percent of any past due benefits to pay toward the fee.

If You Have Any Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find
general information about Social Security. If you have any specific questions, you
may call us toll-free at 1-800-772-1213, or call your local Social Security office
at 409-766-3628. We can answer most questions over the phone. If you are deaf or hard
of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit
any Social Security office. The office that serves your area is located at:

SOCIAL SECURITY

4918-A SEAWALL BLVD

GALVESTON TX 77551

If you do call or visit an office, please have this letter with you. It will help
us answer your questions. Also, if you plan to visit an office, you may call ahead
to make an appointment. This will help us serve you more quickly when you arrive at
the office.